Treatment for a 9-Year-Old with Cough and Sore Throat
For a 9-year-old with cough and sore throat, use ibuprofen or paracetamol for symptom relief and assess the likelihood of streptococcal infection using the Centor score before considering antibiotics. 1
Initial Assessment and Risk Stratification
The first step is to determine whether this is likely bacterial (streptococcal) pharyngitis or a viral upper respiratory infection. Apply the Centor scoring system, which assigns points for: 1
- Tonsillar exudates (1 point)
- Tender anterior cervical lymphadenopathy (1 point)
- Fever >38°C (1 point)
- Absence of cough (1 point)
For children, the modified Centor (McIsaac) score subtracts 1 point if age >15 years or adds 1 point if age 3-14 years. 2 Your 9-year-old patient would receive an additional point for age.
Symptomatic Treatment (All Patients)
Regardless of the Centor score, provide symptomatic relief with ibuprofen or paracetamol (acetaminophen), as these are the recommended first-line treatments for acute sore throat pain. 1
- Honey can be offered for cough relief in children over 1 year of age, as it provides more benefit than no treatment or over-the-counter cough medications 3
- Do not use over-the-counter cough and cold medications in children under 2 years, and they have limited proven efficacy in children under 6 years 4
- Zinc gluconate is not recommended for sore throat 1
Antibiotic Decision Algorithm
The decision to use antibiotics depends entirely on the Centor score: 1, 5
Low Risk (0-2 Centor criteria)
- Do not prescribe antibiotics 1
- These patients have low likelihood of streptococcal infection
- Antibiotics will not meaningfully relieve symptoms in this group 1
Moderate Risk (3 Centor criteria)
- Consider delayed antibiotic prescription (prescription given but patient instructed to wait 2-3 days before filling) 5
- Alternatively, perform rapid antigen detection test (RAT) if available 1
- If RAT is positive, proceed with antibiotics; if negative, throat culture is not necessary 1
High Risk (4+ Centor criteria)
Antibiotic Choice and Duration (If Indicated)
If antibiotics are warranted, penicillin V is the first-line choice, given twice or three times daily for 10 days. 1 However, amoxicillin is equally effective and more palatable for children. 2
Alternative regimens include: 1, 2
- First-generation cephalosporins for penicillin-allergic patients
- Erythromycin or clarithromycin for penicillin allergy
- Azithromycin (12 mg/kg once daily for 5 days) has been shown effective for streptococcal pharyngitis 6
Current evidence does not support shorter treatment durations than 10 days for penicillin. 1 Some guidelines suggest 5-7 days may be adequate, but the traditional 10-day course remains standard. 5
Important Caveats and Red Flags
The modest benefits of antibiotics (shortening symptoms by approximately 1 day) must be weighed against side effects, antimicrobial resistance, and medicalization. 1, 5
Watch for warning signs requiring immediate evaluation: 3
- Respiratory distress (increased work of breathing, nasal flaring, retractions)
- Difficulty swallowing or drooling (suggests epiglottitis or retropharyngeal abscess)
- Toxic appearance
- Stridor (suggests croup or epiglottitis)
- Oxygen saturation <92-94%
Prevention of suppurative complications (peritonsillar abscess) is not a specific indication for antibiotic therapy in routine sore throat. 1 The risk of acute rheumatic fever is extremely low in developed countries. 1
Follow-Up
Reassess the child if symptoms worsen or do not improve within 48 hours. 3, 4 If cough persists beyond 4 weeks, it becomes "chronic cough" and requires systematic evaluation using pediatric-specific algorithms. 1, 4
Provide parents with education about: 4
- Managing fever and maintaining hydration
- Recognizing signs of deterioration
- Expected duration of symptoms (typically 7 days for viral pharyngitis) 5